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P5530

LPN Staffing Shortage on Night Shift

Greensburg, Pennsylvania Survey Completed on 01-23-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to meet the regulatory requirement of providing a minimum of one licensed practical nurse (LPN) per 40 residents during the night shift on one occasion. Specifically, on January 11, 2025, the facility had a census of 112 residents but only provided 17.70 actual LPN hours instead of the required 22.40 hours. This staffing shortage was confirmed by the Nursing Home Administrator during an interview conducted on January 23, 2025.

Plan Of Correction

All residents received appropriate care and services to meet their needs on the identified days and there was no direct correlation to an individual resident. Residents of Hempfield Manor will be protected from future staff ratios below the 1:40 night LPN by a proactive preview of daily staff assignments and schedules to ensure adequate staff coverage by DON/Designee. The nursing scheduler/designee will review projected staffing levels with the DON/designee 3x weekly to ensure that any foreseeable staffing levels below LPN ratios are adequately covered. Weekend and Shift Supervisors will be educated by DON/designee by 2/14/25 to immediately contact all off staff on the nursing list first to see about coverage and next contact DON/ADON for any day that ratios unexpectedly drop below the LPN ratio minimum for immediate resolution. Hempfield Manor will continue to aggressively advertise externally for recruitment of nursing applicants to enhance current staffing levels. Hempfield Manor will also review potential admissions and reconsider admissions if the facility is unable to meet minimum staffing levels. Administrative RNs are assigned to an on-call schedule and are available to cover shifts when foreseeable staffing levels are below the minimum ratio levels. All licensed nursing staff are asked to pick up at least one on-call shift per month and be available for call offs that cause staffing levels to be below the minimum ratio levels. Hempfield Manor offers extra on call pay for on call availability. Hempfield Manor has raised all wages for licensed nursing staff. Staffing ratios will be reviewed by a DON/nursing designee 3x's a week for a month, then weekly x3 weeks then monthly x2 months. Results will be reported on a monthly basis during monthly QAPI committee meeting and at Quarterly Quality Assurance/QAPI meeting.

See complete original report
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